Complex solutions to minimise vascular access complications during iliac branch device implantation after EVAR: a narrative review focusing on planning and technical aspects

INTRODUCTION: Secondary implantation of iliac branch devices (IBDs) after endovascular aortic repair (EVAR) for type Ib endoleak poses unique technical challenges due to altered aortoiliac anatomy and prior femoral access. Selecting an optimal access strategy is critical to minimize complications and ensure procedural success. This review summarizes contemporary transfemoral and upper extremity access techniques, with a focus on modern endovascular solutions that facilitate safe and effective reinterventions. METHODS: A narrative review of the literature published between 2010 and 2025 was conducted using PubMed, focusing on studies reporting technical strategies, outcomes, and complications of secondary IBD implantation after EVAR. Only original research, including technical notes, was included. RESULTS: Across the reviewed studies, upper extremity access was associated with neurologic events, longer operative times, and higher access-site complication rates. Transfemoral "up-and-over" techniques consistently demonstrated technical success rates over 95%, shorter procedural times, and reduced complication rates. Steerable sheath systems enable complete IBD implantation from a single femoral access, with promising safety and efficacy. Technical refinements, including special attention to the prior graft bifurcation and meticulous technique, appear to be key elements to optimising immediate and late outcomes. CONCLUSION: Transfemoral strategies, particularly "up-and-over" techniques using steerable sheaths, appear to be safe and effective alternatives to upper-extremity access for secondary IBD implantation following EVAR. Access strategy should be tailored to patient anatomy and prior graft configuration, with emphasis on minimising vascular trauma, neurologic risk, and procedural complexity.